Charlotte Dargie
The project has been examining the future environment for health in the United Kingdom.
When we started it was decided that the end product would be a futures analysis to examine United Kingdom health policy and policy-making. Our overall aim was to see how planning and policy-making in health in the United Kingdom might benefit from a forward look. We are now at the stage of moving beyond our first assessment and thinking about the policy
implications of that work.
We selected a time horizon of 2015. There were two factors that helped us decide. The first was that we were interested in something that was longer than the electoral cycle and the second was that we needed something that was manageable and containable in terms of the time horizon. The year 2015 seemed to fit with other futures projects that had been carried out, adopting a 10–15-year forward look.
As for how the project has been carried out, the Nuffield Trust set up an advisory group. The people in the group cover a range of specialties within health. They have been involved throughout the project and helped us determine what topics to look at and the approach to take. The research capacity for the project is the research team. I am coordinating the project at the Judge Institute, working with Sandra Dawson and Pam Garside and linking the project to the wider work that the Nuffield Trust is doing.
The way we worked for this first round was to conduct an environmental scan. We approached different specialists to write technical papers covering a range of topics, and asking them to think about trends and issues for the future. As John Wyn Owen mentioned earlier, we picked ten categories for this environmental scan: the global context, physical environment, demography, science and technology, economy and finance, social trends, organisational management, work force issues, ethics and public expectations. We asked the authors to follow a common format in their papers.
The next step was to pull all that information together in an overview report, which we call Pathfinder, to make the link betweenfuture trends and issues identified by the environmental scan and doing something about policy on the basis of that information. We describe it as a policy assessment with a forward look to 2015, asking the question, “what should be done about United Kingdom health policy and what are the gaps in health policy now?” We had quite a task in pulling together all the material in the technical papers into an overview report, to put the issues in as broad a perspective as possible.
We wanted to get across the idea that there were “stocks and flows” in health. We were trying to describe what was happening in a category and what might be the policy recommendations.
We decided to split the themes and issues covered in the report into three categories:
determinants, interventions and outcomes. We then took another step to get from trends and issues to policy recommendations, distilling down from the range of issues covered in the Pathfinderreport to fashion our key messages for government around six themes.
The first theme is people’s expectations and financial sustainability. Expectations of health continue to rise among the population. At the most basic level, people expect to feel safe and secure and the health service contributes to that. People have expectations about how long they are going to live and also the quality of their lives. They have expectations about the type of service they receive when they interact individually with health services, which might include whether and when they are treated and by whom, what alternatives to treatment are offered, how successful the treatment is and how they will recover their health, and whether they have to contribute financially in any way. People have expectations about those who deliver health services to them, which include the ability to communicate with them on a personal basis.
For health policy, people’s expectations need to be recognised and managed. This involves deciding what people expect from health services and how progress towards achieving those
goals is tested. It also means adapting a health system in order for the health workforce to be able to deal with a sophisticated public. Managing public expectations means thinking about the long-term financial sustainability of the health service in its current form in the United Kingdom – providing universal access and funded from general taxation.
The second theme is demography and ageing. The United Kingdom population is becoming older and this trend, in conjunction with a smaller working population to provide taxes to support health services, will affect the dynamics of health services in the medium- and long-term future. We felt that a positive policy agenda would involve dealing with financial
considerations, considering rights and expectations of older people, and developing integrated policies in planning for the health and welfare of older people.
It would also include the evidence base for policy, which involves both more research in the disease profile associated with ageing, and developing broader quality of life indicators for older people on which assessment can take place. Finally, there should be a reorientation of policy towards the individual experience of older people. There should be an understanding of the wider factors affecting people’s lives and the part to be played by relationships with family and friends, their social networks and environment and their ability to participate in society.
The third theme is information and knowledge management. Information technology is raising people’s expectations. Health professionals, along with those in the other sectors, are now trained in information technology. New technology offers many potential benefits, which need to be assessed along with their costs. Patients are able to compare health services with those available outside the United Kingdom, to undertake research into conditions and treatments using the Internet, and to assess how health services make use of information technology when compared with other sectors such as banking and leisure.
The issues of information technology and information and knowledge management raises wider questions about the focus and formulation of health policy for the future. For example, how the new information technology could be used in an integrated way across the health sector, or for sharing policy learning internationally at a European level, or ensuring proper regulation and developing training for health professionals. And could it be used for the effective communication of public policy and of risk?
The fourth theme is scientific advance and new technology. Scientific advances are increasing technical expertise and therapeutic potential. New discoveries are providing new knowledge about preventive strategies and changing what health services do and how they do it (for example, a shift from secondary to tertiary care, from primary care to preventive strategies, and from people to technology).
These developments have consequences for health policy that need to be managed. They also illustrate some of the underlying tensions that exist in health policy. For example, there are those between the new knowledge we can apply in facilitating preventive strategies in society and the right of the individual to refuse treatment; between increasing therapeutic potential and increasing pressure on the health workforce, and between increasingly complex scientific processes in manufacturing and treatment and demands for assurances on safety issues.
A particular impact of scientific advancement generating new knowledge concerns the location of care. On the one hand larger, fewer and more concentrated centres of specialist expertise are
developing, and on the other there is a shift towards treatment outside hospital, including self-diagnosis and home care.
Professional roles are also shifting, and attention needs to be directed towards an assessment of these roles and the associated education and training. We found that the health workforce is under increasing pressure to adapt to new knowledge, new treatments and new ways of working. So the fifth theme is workforce education and training. This needs to be continuous throughout the health professional’s career in order to keep up with evidence and new knowledge in the field.
The health workforce might learn from other sectors in terms of greater flexibility in choice of career patterns, improved incentives and motivation, and greater levels of protection. A longer-term perspective should be taken in workforce planning and alternatives to the current
workforce planning system should be considered.
The sixth theme is system performance and quality. This provokes the question, how well does the health system perform overall? It was felt that the present mechanisms were incomplete for assessing United Kingdom performance, particularly in terms of international comparison.
For the longer term, policy will benefit from using international outcome measures to benchmark the United Kingdom. There needs to be more work on the development of outcome measures, which can be used to evaluate health policy. Policy and performance measures currently being developed in the United Kingdom that are focused on monitoring, evaluation and review should be extended to the performance of the system overall in addition to specific services within it.
What does this all mean in terms of where are we now in the project? The project now presents an agenda for health, and that is what we set out to establish. We certainly do not think that we have answers to the questions that we have raised, but the aim at this stage is to raise those questions and to promote the idea of new, innovative and long-term strategic thinking in order to determine the future of health.
In terms of other work that was going on, we could not see whether anyone else was taking the broad perspective of trying to pull together the trends and issues in the various sectors of health to provide an overall picture of where health is now, where we might be going, and therefore what we should do.
And, finally, who is the agenda for? So far, we think it is the policy-makers, the staff, the patients, the consumers of health services and the public. We have tried to address the consumer by putting the papers out to consultation, a process that has just come to an end.
And now we are embarking on a second process, where we think about what people have reflected back to us in terms of the recommendations and how we pull it all together in a summary of issues for government.
Cristina Puentes-Markides
What we are seeing now in the United States, and also in Canada, is some recognition that the way the health services system is structured really can affect health by jeopardising access or utilisation. We really need to take another look at the way we are structuring systems.
Laura Balbo
Charlotte Dargie talked about a “sophisticated public” with rising expectations. Not only do
people want to get better, they want a good relationship. And in the report there is reference to an informed and demanding patient. The right to refuse treatment was mentioned, but there could even be discussion of the right to choose the moment of one’s death. This is the kind of public we already have, and certainly the one we are going to have. It is not just changes in the health care delivery system but the fact that people are informed, demanding, sophisticated. I was very pleased to see that this was one of the issues that had been identified.
Charlotte Dargie
This issue came out more strongly as we went on with the project. We started in terms of thinking what might be the technical or environmental drivers in terms of health. When it came to considering what technical papers we should commission, public expectations came up, and then in the discussions that followed it became a much stronger issue.
It has been brought to our attention since that there is often a simplifying assumption made that there is just one set of public or people’s expectations. Rather than assuming a demanding public, we should be thinking more about different groups of people. In that case, we need to explore the mechanisms that can be used to respond to their different expectations. More work is needed on that.
Cristina Puentes-Markides
We have been told that one of the purposes of the project was to raise issues for policy-makers. Then we were introduced to the sophisticated consumer. What happens to the
“unsophisticated public”? How could this project be used to raise issues among all kinds of publics?
Charlotte Dargie
Our initial remit was to identify messages for government and we have developed an agenda that is directed towards ministers. The projects undertaken by government itself, for example Foresight, have the capacity to engage with the public in a much more wide-ranging way than we would be able to. But if we can push for issues to be put on the government agenda and for policy discussions at that level, and if policy were then changed as a result, then we would say that we have had an impact.
One of the questions that we have asked ourselves is how we would measure the project’s success. Would or should it be how we got issues on to the government agenda, or the number of people who now know about the project, or the number of local groups we have helped to consider the impact of the issues on them?
We do know the number of visits to the Nuffield Trust’s web site and the number of people who are accessing the reports. We are also aware of the interest among local health services; they would like to use the work or run scenario exercises or consultation exercises in their local areas. Certainly in that way the project would reach a wider public than we could ourselves.
Pam Garside
I personally got quite frustrated when we received the paper we had commissioned on public expectations. It responded to what we asked for, but it led us to think that we needed a much more sophisticated look at the issue: what is the public, how do they engage as individuals, sophisticated or non-sophisticated? We have started something that we want to look at further. Hence, we deliberately called one of the six themes “sustainable financing and people’s expectations”.
Tim Willis
Reaching the public is one of the Foresight objectives. We use patient groups, charities and the women’s voluntary sector, among others. When we became aware of new types of initiative in primary health care – say a new use of information technology to strengthen links with the population in a deprived area – we involved the innovators in the work of Foresight. But it really is difficult to identify the public. How is it done in the United States?
Cristina Puentes-Markides
It is difficult because, consciously or not, our cultural, professional, gender and socioeconomic biases determine how we look at the world. In preparing the United States’ health promotion and disease prevention policy for 2010, the consultation meetings engaged a variety of people, professional associations, associations of patients, some business advisory groups and the faith communities.
Nevertheless, however you look at it, the problem in the developing world is similar. Social policies in Latin America do not always reach the people who are truly disadvantaged.
Including people and reaching them through social policies and programmes may need different ways of thinking and approaching health issues.
Graham Lister
As chairman of a United Kingdom patient-based organisation, I would like to stress that we should not take this sort of social capital for granted. It requires investment and support. In the Netherlands, one in five people are members of a patient-based association. This is partly due to a history of civic engagement, but one of the reasons is that the government has invested in an infrastructure, the Netherlands Patient/Consumer Association, which supports patient organisations and patient advocacy and provides information and ways of looking at the world from the patient’s perspective.
Ann Taket
The presentation concentrated most on health services and the health service system. What has been coming through about what the response could, should be or is in the other sectors that impinge on health?
Charlotte Dargie
That is quite difficult. It partly relates to the design of the project, which was a secondary analysis looking at the trends and issues that could be discerned from the published literature and other reports. When it came to thinking as a group, we felt at the beginning of the project that we were taking a broad perspective. But looking at actual interventions, we were drawn more into what the health services can do. The difficulty is thinking in terms of policy recommendations. We first have to determine who has responsibility for health policy and where responsibility should lie. We thought about it, and we have not really answered it. We are still at the stage of asking questions.
Sandra Dawson
We need to be very focused and to draw attention to the things that are most important. I think we have to be clear how ministers would know in one or five years’ time whether the recommendations that we had suggested had made a difference. We need to know not only how we should judge the success of the project, but also how the recommendations that we bring forward could be benchmarked on hard data.
Question:What view did you come to on health inequalities and social exclusion?
Charlotte Dargie
After we had received all the technical papers we held a workshop in which we tried to identify issues that cut across all the topics we had covered; if one issue stood out, it was health inequalities. The information in the public domain about widening inequalities in health has recently become an issue in the United Kingdom.
There is the difficulty of measurement and benchmarking. I noted the point made by Ilona Kickbusch on the argument of having social rather than just health indicators. We have looked at the work that the Joseph Rowntree Foundation is doing in terms of indicators and playing a monitoring role. We do not have the capacity to undertake the Rowntree type of monitoring project, but I see it as an overall aim of the project that there should be a monitoring capacity and time for issues like that.
Sandra Dawson
Although social exclusion was high on the government agenda, we found very little optimism
Although social exclusion was high on the government agenda, we found very little optimism